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Background
Blepharoplasty refers to surgery to remove excess skin and fatty tissue around the eyes. Blepharochalasis is a term used to refer to loose or baggy skin (dermatochalasis) above the eyes, so that a fold of skin hangs down, often concealing the tarsal margin when the eye is open. In severe cases, excess skin and fat above the eyes can sit on the upper eyelid and may obstruct the superior field of vision. Blepharochalasis may cause pseudoptosis (false ptosis), where the patient has a normal ability to elevate the eyelid, but bagging skin above the eye overhangs the eyelid margin, resembling ptosis. In some cases, excess skin around the eye may cause the eyelashes to turn in and to irritate the eye, or turn outward, resulting in exposure keratitis.
Surgical removal of these overhanging skin folds may improve the function of the upper eyelid and restore peripheral vision. Blepharoplasty is also performed for cosmetic reasons to improve a sagging, tired appearance, and is the second most common aesthetic procedure performed by plastic surgeons. For coverage of this procedure, photographs in straight gaze should show sagging tissue above the eyes that is resting on or pushing down on the eyelashes.
Blepharoplasty to remove excess tissue either above or below the eyes may also be medically necessary and covered to correct prosthesis difficulties in an anophthalmia socket, to repair defects caused by trauma or tumor-ablative surgery, to correct an entropion (inward turned eyelid) or extropion (outward turned eyelid), to treat periorbital sequelae of thyroid disease and nerve palsy, and to relieve painful blepharospasm.
Ptosis (also called blepharoptosis) is the term for drooping of one or both upper eyelids. This may occur in varying degrees from slight drooping to complete closure of the involved eyelid. In the most severe cases, the drooping can obstruct the visual field and cause positional head changes.
There are two types of ptosis, acquired and congenital. Acquired ptosis is more common. Congenital ptosis is present at birth. Ptosis may occur because the levator muscle's attachment to the lid is weakening with age. Acquired ptosis can also be caused by a number of different things, such as disease that impairs the nerves, diabetes, injury, tumors, inflammation, or aneurysms. Congenital ptosis may be caused by a problem with nerve innervation or a weak muscle. Drooping eyelids may also be the result of diseases such as myotonic dystrophy or myasthenia gravis.
The primary symptom of ptosis is a drooping eyelid. Adults will notice a loss of visual field because the upper portion of the eye is covered. Children who are born with a ptosis usually tilt their head back in an effort to see under the obstruction. Some people raise their eyebrows in order to lift the lid slightly and therefore may appear to be frowning.
Diagnosis of ptosis is usually made by observing the drooping eyelid. Ptosis is usually treated surgically. Surgery can generally be done on an outpatient basis under local anesthetic. For minor drooping, a small amount of the eyelid tissue can be removed. For more pronounced ptosis the approach is to surgically shorten the levator muscle or connect the lid to the muscles of the eyebrow. Or, the aponeurosis can be reattached to the tarsal plate if it had separated. Correcting the ptosis is usually done only after determining the cause of the condition.
Ptosis (blepharoptosis) repair for laxity of the muscles of the upper eyelid causing functional visual impairment is covered when photographs in straight gaze show the eyelid margin across the midline or at the most 1 or 2 mm above the midline of the pupil (see Figure).
Figure: Diagram of upper lid margin crossing the pupil
To demonstrate the medical necessity of both blepharoplasty and ptosis (blepharoptosis) repair, two photographs may be needed. One photograph should demonstrate the excess skin above the eyes resting on the eyelashes. A second photograph should be taken with the excess skin lifted off of the eyelashes (such as by taping the excess skin to the forehead), and demonstrating persistence of ptosis with the lid margin across the midline of the pupil or 1 to 2 mm above the pupil midline.
Brow ptosis refers to sagging tissue of the eyebrows and/or forehead. In extreme cases, brow ptosis can obstruct the field of vision. Brow ptosis is caused by aging changes in the forehead muscle and skin, which leads to weakening of these tissues and sagging of the eyebrows. Brow ptosis is treated surgically with the specific operation being based on the amount and location of the brow ptosis.
Brow ptosis surgery is usually performed under local anesthesia as an outpatient procedure. Excess skin and muscle is excised and the deep tissues are sutured together. Brow ptosis repair for laxity of the forehead muscles causing functional visual impairment is covered when photographs show the eyebrow below the supraorbital rim.
Often brow ptosis coexists with eyelid ptosis and dermatochalasis; in these cases, ptosis surgery and blepharoplasty may be performed at the time of the brow ptosis surgery. The medical necessity of each surgical procedure may need to be demonstrated with separate photographs: one photograph should show the eyebrow below the supraorbital rim, a second photograph with the sagging forehead lifted up in order to see the sagging tissue above the eye resting on the eyelashes, and then a third with the sagging tissue lifted off of the eyelid in order to see the persistent lid lag (ptosis).
Visual field testing is not necessary to determine the presence of excess upper eyelid skin, upper eyelid ptosis, or brow ptosis. A patient could cause a visual field defect by lowering their lids during the test. Photographs that document eyelids crossing the pupils provide a practical indication for the need of surgery.
If visual field tests are performed, the tests should show loss of two-thirds or greater of a visual field in the upper or temporal areas documented by computerized visual field studies, with visual field restored by taping or holding up the upper lid.
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